MWL Related Safety Recommendations

Page Content

The table below provides a listing of open NTSB recommendations most strongly associated with the 10 Most Wanted List (MWL) issues. The recommendations are grouped by each MWL issue. In addition to the recommendation number, classification status and recommendation text, each recommendation listed also contains a hyperlink to the NTSB’s safety recommendation database where additional detail about that specific recommendation can be found.​

​

Reduce Fatigue-Related Accid​​ents​

Rec #

Status

Text

Link

Requires
or possibly requires regulatory action

A-13-001

Open—Unacceptable Response

TO THE FEDERAL
AVIATION ADMINISTRATION: Establish duty-time regulations for maintenance
personnel working under [Title] 14 Code of Federal
Regulations Parts 121, 135, 145, and 91 subpart K
that take into consideration factors such as start time, workload, shift
changes, circadian rhythms, adequate rest time, and other factors shown by
recent research, scientific evidence, and current industry experience to
affect maintenance crew alertness. (Supersedes Safety Recommendation A-97-71)

TO
THE FEDERAL AVIATION ADMINISTRATION: Require that personnel performing
maintenance or inspections under [Title] 14 Code of
Federal Regulations Parts 121, 135, 145, and 91
subpart K receive initial and recurrent training on human factors affecting
maintenance that includes a review of the causes of human error, including
fatigue, its effects on performance, and actions individuals can take to prevent
the development of fatigue.

TO
UPS (UNITED PARCEL SERVICE) AIRLINES: Work with the Independent Pilots
Association to conduct an independent review of the fatigue event reporting
system to determine the program’s effectiveness as a nonpunitive mechanism to
identify and effectively address the reported fatigue issues. Based on the
findings, implement changes to enhance the safety effectiveness of the
program.

TO
THE FEDERAL AVIATION ADMINISTRATION:
Revise the Federal Aviation Regulations contained in [Title] 14 CFR Part 135 to require that pilot
flight time accumulated in all company flying conducted after revenue
operations-such as training and check flights, ferry flights and
repositioning flights-be included in the crewmember's total flight time
accrued during revenue operations.

TO
THE FEDERAL AVIATION ADMINISTRATION:
Finalize the review of current flight and duty time regulations and
revise the regulations, as necessary, within 1 year to ensure that flight and
duty time limitations take into consideration research findings in fatigue
and sleep issues. The new regulations
should prohibit air carriers from assigning flightcrews to flights conducted
under [Title] 14 Code of Federal Regulations (CFR)
Part 91 unless the flightcrews meet the flight and duty time limitations of
14 CFR Part 121 or
other appropriate regulations.

TO
THE AMERICAN BUS ASSOCIATION AND THE UNITED MOTORCOACH ASSOCIATION: Inform your members through Web sites,
newsletters, and conferences of the circumstances of the Mexican Hat, Utah,
accident. The prepared information should encourage charter operators to
develop written contingency plans for each charter to ensure that trip
planning is in place in the event of driver fatigue, incapacitation, or
illness or in the event of trip delays necessitating replacement drivers to avoid hours-of-service
violations and inform drivers of their trip’s contingency plans. The prepared
information should also provide information about the risks of operating in
rural areas without wireless telephone coverage and advise members to carry
mobile cellular amplifiers or satellite-based devices to communicate
emergency events.

TO
ARROW STAGE LINES: Develop written contingency plans for each charter to
ensure that trip planning is in place in the event of driver fatigue,
incapacitation, or illness or in the event of trip delays necessitating
replacement drivers to avoid hours-of-service violations and inform drivers
of their trip’s contingency plans.

TO
THE FEDERAL MOTOR CARRIER SAFETY ADMINISTRATION: Implement a program to
identify commercial drivers at high risk for obstructive sleep apnea and
require that those drivers provide evidence through the medical certification
process of having been appropriately evaluated and, if treatment is needed,
effectively treated for that disorder before being granted unrestricted
medical certification.

TO
THE FEDERAL MOTOR CARRIER SAFETY ADMINISTRATION: Develop and disseminate guidance for
commercial drivers, employers, and physicians regarding the identification
and treatment of individuals at high risk of obstructive sleep apnea (OSA),
emphasizing that drivers who have OSA that is effectively treated are
routinely approved for continued medical certification.

TO
THE FEDERAL MOTOR CARRIER SAFETY ADMINISTRATION: Require all motor carriers
to adopt a fatigue management program based on the North American Fatigue
Management Program guidelines for the management of fatigue in a motor
carrier operating environment.

TO
THE FEDERAL MOTOR CARRIER SAFETY ADMINISTRATION: Incorporate scientifically
based fatigue mitigation strategies into the hours-of-service regulations for
passenger-carrying drivers who operate during the nighttime window of
circadian low.

TO
24 STATES, GUAM, AND THE COMMONWEALTH OF PUERTO RICO: Require local pilot
oversight organizations that have not already done so to implement fatigue
mitigation and prevention programs that (1) regularly inform mariners of the
hazards of fatigue and effective strategies to prevent it and (2) promulgate
hours of service rules that prevent fatigue resulting from extended hours of
service, insufficient rest within a 24-hour period, and disruption of
circadian rhythms.

TO
THE UNITED STATES COAST GUARD: Address the risks associated with watch
stander fatigue by implementing Commandant Instruction 3500.2, Crew Endurance
Management, issued on March 30, 2006, in all operational units.

TO
THE FEDERAL TRANSIT ADMINISTRATION: Require transit agencies, through the
system safety program and hazard management process if necessary, to ensure
that the time off between daily tours of duty, including regular and overtime
assignments, allows train operators to obtain at least 8 hours of
uninterrupted sleep.

TO
THE FEDERAL TRANSIT ADMINISTRATION: Develop and disseminate guidance for
operators, transit authorities, and physicians regarding the identification
and treatment of individuals at high risk for obstructive sleep apnea and
other sleep disorders.

TO
46 US RAIL TRANSIT AGENCIES: Review your medical history and physical
examination forms and modify them as necessary to ensure that they elicit
specific information about any previous diagnosis of obstructive sleep apnea
or other sleep disorders and about the presence of specific risk factors for
such disorders.

TO
46 US RAIL TRANSIT AGENCIES: Establish a program to identify operators who
are at high risk for obstructive sleep apnea or other sleep disorders and
require that such operators be appropriately
evaluated and treated.

TO
THE FEDERAL RAILROAD ADMINISTRATION: Require the implementation of methods
that can identify fatigue and mitigate performance decrements associated with
fatigue in on-duty train crews that are identified or developed in response
to Safety Recommendation R-12-18.

TO
THE BNSF RAILWAY: Require all employees and managers who perform or supervise
safety-critical tasks to complete fatigue training on an annual basis and
document when they have received this training.

TO
THE FEDERAL RAILROAD ADMINISTRATION: Develop medical certification
regulations for employees in safety-sensitive positions that include, at a
minimum, (1) a complete medical history that includes specific screening for
sleep disorders, a review of current medications, and a thorough physical
examination, (2) standardization of testing protocols across the industry,
and (3) centralized oversight of certification decisions for employees who
fail initial testing; and consider requiring that medical examinations be
performed by those with specific training and certification in evaluating
medication use and health issues related to occupational safety on railroads.
[This recommendation supersedes Safety Recommendations R-02-24 through -26.]

TO
METRO-NORTH RAILROAD: Develop and implement protocols to routinely screen and
fully evaluate your safety-sensitive employees for sleep disorders and ensure
that such disorders are adequately addressed if diagnosed.

TO
THE LONG ISLAND RAILROAD: Develop and implement protocols to routinely screen
and fully evaluate your safety-sensitive employees for sleep disorders and
ensure that such disorders are adequately addressed, if diagnosed.

TO
THE ASSOCIATION OF AMERICAN RAILROADS, THE AMERICAN PUBLIC TRANSPORTATION
ASSOCIATION, THE AMERICAN SHORT LINE AND REGIONAL RAILROAD ASSOCIATION, THE
BROTHERHOOD OF LOCOMOTIVE ENGINEERS, AND THE INTERNATIONAL ASSOCIATION OF
SHEET METAL, AIR, RAIL AND TRANSPORTATION WORKERS: Collaborate to develop a
model national labor agreement that supports effective programs for
addressing sleep disorders and other medical conditions among
safety-sensitive train operating personnel.

TO
THE TO THE AMERICAN COLLEGE OF PHYSICIANS: Enhance initial and ongoing
training to ensure that Board-certified physicians in Internal Medicine can
successfully identify the risk factors for, evaluate, and effectively treat
obstructive sleep apnea among their patients.

TO
THE AMERICAN ACADEMY OF FAMILY PHYSICIANS: Enhance initial and ongoing
training to ensure that Board-certified physicians in Family Medicine can
successfully identify risk factors for, evaluate, and effectively treat
obstructive sleep apnea among their patients.

TO
THE FEDERAL TRANSIT ADMINISTRATION: Develop a work scheduling program for
rail transit agencies that incorporates fatigue science—such as validated
biomathematical models of fatigue—and provides for the management of
personnel fatigue risks, and implement the program through the state safety
oversight program.

TO
THE FEDERAL TRANSIT ADMINISTRATION: Establish (through the state safety
oversight program) scientifically based hours-of-service regulations that set
limits on hours of service, provide predictable work and rest schedules, and
consider circadian rhythms and human sleep and rest requirements.

TO
THE FEDERAL TRANSIT ADMINISTRATION: Identify the necessary training and
certification needs for work schedulers in the rail transit industry and
require the transit agencies—through the state safety oversight program—to
provide additional training or certification for their work schedulers.

TO
THE FEDERAL TRANSIT ADMINISTRATION: Require (through the state safety
oversight program) rail transit employees who develop work schedules to
complete initial and recurrent training based on current fatigue science to
identify and mitigate work schedule risks that contribute to operator
fatigue.

TO
THE FEDERAL RAILROAD ADMINISTRATION: Require freight railroads to use
validated biomathematical fatigue models, similar to the models used by
passenger railroads, to develop work schedules that do not pose an excessive
risk of fatigue.

TO
BNSF RAILWAY, CANADIAN NATIONAL RAILWAY, CANADIAN PACIFIC RAILWAY, CSX
TRANSPORTATION, KANSAS CITY SOUTHERN RAILWAY, NORFOLK SOUTHERN RAILWAY,
INTERCITY RAILROADS, AND COMMUTER RAILROADS: Review and revise as necessary
your medical rules, standards, or protocols to ensure you are informed of any
diagnosed sleep disorders that employees in safety-sensitive positions must
report and, when an employee makes such a report, perform periodic
evaluations to ensure the condition is appropriately treated and the employee
is fit for duty.

TO
CLASS I RAILROADS: Revise your scheduling practices for train crews and
implement science-based tools, such as validated biomathematical models, to
reduce start time variability that results in irregular work-rest cycles and
fatigue.

TO
UNION PACIFIC RAILROAD: Revise your medical rules to add any diagnosed sleep
disorder to the list of medical conditions that employees in safety-sensitive
positions must report and, when an employee makes such a report, perform
periodic evaluations to ensure the condition is appropriately treated and the
employee is fit for duty.

Strengthen Occupant
Protection

Rec #

Status

Text

Link

Requires
or possibly requires regulatory action

A-14-044

Open—Acceptable Response

TO THE FEDERAL
AVIATION ADMINISTRATION: Conduct research that examines the injury potential
to occupants in accidents with significant lateral forces, and if the
research deems it necessary, implement regulations to mitigate the hazards
identified.

TO
THE FEDERAL AVIATION ADMINISTRATION: Conduct research to identify the
mechanism that produces high thoracic spinal injuries in commercial aviation
accidents, and if the research deems it necessary, implement regulations to
mitigate the hazards identified.

TO
THE FEDERAL AVIATION ADMINISTRATION: Once Airbus Helicopters completes
development of a retrofit kit to incorporate a crash-resistant fuel system
into AS350B3e and similarly designed variants, prioritize its approval to
accelerate its availability to operators.

TO
THE FEDERAL AVIATION ADMINISTRATION: Issue a special airworthiness
information bulletin (SAIB) informing all owners and operators of AS350 B3e
and similarly designed variants of the availability of a crash-resistant fuel
system retrofit kit and urging that it be installed as soon as practicable.
To encourage helicopter owners and operators to retrofit existing helicopters
with a crash-resistant fuel system, the SAIB should also discuss the
helicopter accidents cited in this report.

TO
THE FEDERAL AVIATION ADMINISTRATION: Issue a special airworthiness
information bulletin that is periodically updated to inform all helicopter
owners and operators about available modifications to improve fuel system
crashworthiness and urge that they be installed as soon as practicable. To
encourage helicopter owners and operators to retrofit existing 2 helicopters
with a crash-resistant fuel system, the SAIB should also discuss the
helicopter accidents cited in this report.

TO
THE EUROPEAN AVIATION SAFETY AGENCY: Once Airbus Helicopters completes
development of a retrofit kit to incorporate a crash-resistant fuel system
into AS350 B3e and similarly designed variants, prioritize its approval to
accelerate its availability to operators.

TO
THE ASSOCIATION OF CRITICAL CARE TRANSPORT: In collaboration with the
Association of Air Medical Services and the Air Medical Operators
Association, establish a working group to develop and distribute guidelines,
for those who purchase, lease, or contract for helicopters, regarding the
equipment and systems that would enhance the helicopters’ crashworthiness,
including, at a minimum, a crash-resistant fuel system and energy-absorbing
seats.

TO
THE ASSOCIATION OF AIR MEDICAL SERVICES AND AIR MEDICAL OPERATORS
ASSOCIATION: Work with the Association of Critical Care Transport to
establish a working group to develop and distribute guidelines, for those who
purchase, lease, or contract for helicopters, regarding the equipment and
systems that would enhance the helicopters’ crashworthiness, including, at a
minimum, a crash-resistant fuel system and energy-absorbing seats.

TO
THE STATES AND THE DISTRICT OF COLUMBIA CHILD CARE TRANSPORTATION OVERSIGHT
AGENCIES: Implement an oversight program for child care transportation that
includes the following elements: A requirement that occupants wear
age-appropriate restraints at all times.

TO
THE NATIONAL ASSOCIATION FOR THE EDUCATION OF YOUNG CHILDREN: As part of your
accreditation program, establish a transportation safety accreditation that
requires applicants to implement the following elements:

Use of vehicles built to school bus standards or of multifunction school
activity buses;

A regular vehicle maintenance and inspection program;

A requirement that occupants wear age-appropriate restraints at all times;

A requirement that drivers receive a criminal background check and have a
medical examination to determine fitness to drive;

Preemployment, random, postaccident, and "for cause" drug testing
for all child care transportation providers and the prohibition of anyone who
tests positive for drugs from transporting children;

TO
THE NATIONAL HIGHWAY TRAFFIC SAFETY ASSOCIATION: Evaluate the effects of seat
spacing and armrests as factors for potential occupant injury, and if safer
spacing or armrest configurations are identified, develop and implement
appropriate guidelines.

TO
THE STATES OF CALIFORNIA, FLORIDA, LOUISIANA, NEW JERSEY, NEW YORK, AND
TEXAS: Develop: (1) a handout for your school districts to distribute
annually to students and parents about the importance of the proper use of
all types of passenger seat belts on school buses, including the potential
harm of not wearing a seat belt or wearing one but not adjusting it properly;
and (2) training procedures for schools to follow during the twice yearly
emergency drills to show students how to wear their seat belts properly.

TO
THE STATES OF CALIFORNIA, FLORIDA, LOUISIANA, NEW JERSEY, NEW YORK, AND
TEXAS: Upon publication of the National School Transportation Specifications
and Procedures document, revise the handout and training procedures developed
in Safety Recommendation H-13-32 to align with the national procedures as
appropriate.

TO
THE NATIONAL ASSOCIATION OF STATE DIRECTORS OF PUPIL TRANSPORTATION SERVICES,
NATIONAL ASSOCIATION FOR PUPIL TRANSPORTATION, NATIONAL SCHOOL TRANSPORTATION
ASSOCIATION, SCHOOL BUS MANUFACTURERS TECHNICAL COUNCIL, AND NATIONAL SAFETY
COUNCIL, SCHOOL TRANSPORTATION SECTION: Develop guidelines and include them
in the next update of the National School Transportation Specifications and
Procedures to assist schools in training bus drivers, students, and parents
on the importance and proper use of school bus seat belts, including manual
lap belts, adjustable lap and shoulder belts, and flexible seating systems.

TO
THE NATIONAL ASSOCIATION OF STATE DIRECTORS OF PUPIL TRANSPORTATION SERVICES,
NATIONAL ASSOCIATION FOR PUPIL TRANSPORTATION, AND NATIONAL SCHOOL
TRANSPORTATION ASSOCIATION: Provide your members with educational materials
on lap and shoulder belts providing the highest level of protection for
school bus passengers, and advise states or school districts to consider this
added safety benefit when purchasing seat belt-equipped school buses.

TO
THE SCHOOL BUS MANUFACTURERS TECHNICAL COUNCIL: Develop a recommended
practice for establishing and safeguarding the structural integrity of the
entire school bus seating and restraint system, including the seat pan
attachment to the seat frame, in severe crashes—in particular, those
involving lateral impacts with vehicles of large mass.

TO
THE FEDERAL MOTOR CARRIER SAFETY ASSOCIATION: Update your website guidance to
include information on the mandated three-point restraints effective November
2016 for all new over-the-road buses and for other than over-the-road buses
with a gross vehicle weight rating greater than 11,793 kilograms (26,000
pounds).

TO
THE NATIONAL LIMOUSINE ASSOCIATION: Develop and distribute guidelines to your
member operators urging them, during pretrip safety briefings, to (1) direct
passengers to use seat belts where required by law and strongly encourage
passengers to use seat belts where not required by law, and (2) encourage
passengers to use properly adjusted head restraints.

TO
THE FIFTY STATES, DISTRICT OF COLUMBIA, AND PUERTO RICO: Enact legislation
that provides for primary enforcement of a mandatory seat belt use law for
all vehicle seating positions equipped with a passenger restraint system.
(Safety Recommendation H-15-042 supersedes Safety Recommendation H-97-2)

TO
THE AMERICAN BUS ASSOCIATION AND THE UNITED MOTORCOACH ASSOCIATION: Encourage
member passenger-carrying companies to (1) establish procedures to ensure
that the seat belts on all buses are regularly inspected to maintain their
functionality and accessibility, and (2) provide pretrip safety briefings
emphasizing the benefits of seat belt use.

TO
GREYHOUND LINES, INC.: Provide pretrip safety briefings at all stops prior to
departure when taking on new passengers, which describe the use of the
emergency exits and the benefits of wearing seat belts.

TO
THE 50 STATES, THE 5 US TERRITORIES, AND THE DISTRICT OF COLUMBIA: Review
existing laws and enact legislation, if needed, that would: ensure that
children up to 8 years old are required by the state's mandatory child
restraint use law to use child restraint systems and booster seats.

TO
THE NATIONAL HIGHWAY TRAFFIC SAFETY ADMINISTRATION: Expand your research on
current advanced glazing to include its applicability to motorcoach occupant
ejection prevention, and revise window glazing requirements for newly
manufactured motorcoaches based on the results of this research.

TO
THE NATIONAL HIGHWAY TRAFFIC SAFETY ADMINISTRATION: In 2 years, develop
performance standards for motorcoach roof strength that provide maximum
survival space for all seating positions and that take into account current
typical motorcoach window dimensions.

TO
THE UNITED STATES COAST GUARD: Amend Navigation and Vessel Inspection
Circular 1-01 to ensure that (1) amphibious passenger vehicle (APV) operators
tell passengers that seat belts must not be worn while the vessel/vehicle is
operated in the water and (2) before the APV enters the water or departs the
dock, the master or other crewmember visually checks that each passenger has
unbuckled his or her seat belt.

TO
THE UNITED STATES COAST GUARD: Distribute a safety alert on amphibious
passenger vehicle operations that addresses the role of risk assessment to
mitigate driver distraction, as well as the need to tell passengers to remove
seat belts before waterborne operations begin.

TO
THE PASSENGER VESSEL ASSOCIATION: Notify all your amphibious passenger
vehicle (APV) operator members of the importance of the following: (1)
learning the lessons from the Seattle, Washington, and Boston, Massachusetts,
crashes; (2) completing proper maintenance and service bulletin repairs; (3)
using the pretrip safety orientation to tell passengers of APVs equipped with
passenger seat belts to unbuckle their belts before the APV begins any marine
operations; (4) conducting a visual inspection to ensure that passengers have
unbuckled their seat belts prior to water entry; (5) reducing the risk of
driver distraction by having a tour guide conduct each tour; (6) managing
risk in tour operations by addressing such factors as driver distraction,
route planning, vehicle characteristics, traffic density, and vehicle speed;
and (7) conducting operations according to Navigation and Vessel Inspection
Circular 1-01 guidance and US Coast Guard safety alerts.

TO
THE FEDERAL TRANSIT ADMINISTRATION: Develop minimum crashworthiness standards
to prevent the telescoping of transit railcars in collisions and establish a
timetable for removing equipment that cannot be modified to meet the new
standards.

TO
THE WASHINGTON METROPOLITAN TRANSIT AUTHORITY: Remove all 1000-series
railcars as soon as possible and replace them with cars that have
crashworthiness collision protection at least comparable to the 6000-series
railcars.

TO
THE FEDERAL RAILROAD ADMINISTRATION: Revise Title 49 Code
of Federal Regulations Part 229 to ensure the
protection of the occupants of isolated locomotive operating cabs in the
event of a collision. Make the revision applicable to all locomotives,
including the existing fleet and those newly constructed, rebuilt,
refurbished, and overhauled, unless the cab will never be occupied.

TO
THE FEDERAL RAILROAD ADMINISTRATION: Revise Title 49 Code
of Federal Regulations Part 229 to require
crashworthiness performance validation for all new locomotive designs under
conditions expected in a collision.

TO
THE FEDERAL RAILROAD ADMINISTRATION: Once the side impact crashworthiness
standards are developed in Safety Recommendation R-12-39, revise [Title] 49 Code of Federal Regulations 238.217,
“Side Structure,” to require that new passenger railcars be built to these
standards.

TO
THE FEDERAL RAILROAD ADMINISTRATION: Develop a performance standard to ensure
that windows (e.g., glazing, gaskets, and any retention hardware) are
retained in the window opening structure during an accident and incorporate
the standard into [Title] 49 Code of Federal Regulations (CFR)
238.221 and 49 CFR
238.421 to require that passenger railcars meet this standard.

TO
THE FEDERAL RAILROAD ADMINISTRATION: Conduct research to evaluate the causes
of passenger injuries in passenger railcar derailments and overturns and
evaluate potential methods for mitigating those injuries, such as installing
seat belts in railcars and securing potential projectiles

TO
THE FEDERAL RAILROAD ADMINISTRATION: When the research specified in Safety
Recommendation R-16-35 identifies safety improvements, use the findings to
develop occupant protection standards for passenger railcars to mitigate
passenger injuries likely to occur during derailments and overturns.

TO
THE NATIONAL HIGHWAY TRAFFIC SAFETY ADMINISTRATION: Once the performance
standards requested in H-13-13 have been developed, require newly
manufactured single-unit trucks with gross vehicle weight ratings over 10,000
pounds to be equipped with side underride protection systems meeting the
performance standards.

TO
THE NATIONAL HIGHWAY TRAFFIC SAFETY ADMINISTRATION: Once the performance
standards requested in H-13-15 have been developed, require newly
manufactured single-unit trucks with gross vehicle weight ratings over 10,000
pounds to be equipped with rear underride protection systems meeting the
performance standards.

TO
THE NATIONAL HIGHWAY TRAFFIC SAFETY ADMINISTRATION: Require that newly
manufactured trailers with gross vehicle weight ratings over 10,000 pounds be
equipped with side underride protection systems that will reduce underride
and injuries to passenger vehicle occupants.

TO
THE NATIONAL HIGHWAY TRAFFIC SAFETY ADMINISTRATION: Require that newly
manufactured truck-tractors with gross vehicle weight ratings over 26,000
pounds be equipped with side underride protection systems that will reduce
underride and injuries to passenger vehicle occupants.

Expand Recorder Use
to Enhance Safety

Rec #

Status

Text

Link

Requires
or possibly requires regulatory action

A-09-090

Open—Acceptable Response

TO THE FEDERAL
AVIATION ADMINISTRATION: Require helicopter emergency medical services
operators to install flight data recording devices and establish a structured
flight data monitoring program that reviews all available data sources to
identify deviations from established norms and procedures and other potential
safety issues.

TO
40 PUBLIC OPERATORS OF EMS HELICOPTERS: Install flight data recording devices
and establish a structured flight data monitoring program that incorporates
routine reviews of all available sources of information to identify
deviations from established norms and procedures and other potential safety
issues.

TO
THE FEDERAL AVIATION ADMINISTRATION: Require [Title] 14 Code
of Federal Regulations Part 121, 135, and 91K
operators to (1) routinely download and analyze all available sources of
safety information, as part of their flight operational quality assurance
program, to identify deviations from established norms and procedures; (2)
provide appropriate protections to ensure the confidentiality of the
deidentified aggregate data; and (3) ensure that this information is used for
safety-related and not punitive purposes.

TO
THE UNITED STATES DEPARTMENT OF AGRICULTURE, FOREST SERVICE: Require all
contracted transport-category helicopters to be equipped with a cockpit voice
recorder and a flight data recorder or a cockpit image recorder with the
capability of recording cockpit audio, crew communications, and aircraft
parametric data.

TO
THE FEDERAL AVIATION ADMINISTRATION: Revise Federal Aviation Administration
Order 8130.2G and related guidance or regulations, as necessary, to include
provisions for the use of electronic data recordings from electronic flight
displays, engine instruments, or other recording devices in support of Phase
I flight testing of experimental amateur-built aircraft to document the
aircraft performance data and operating envelope and develop an accurate and
complete aircraft flight manual.

TO
THE EXPERIMENTAL AIRCRAFT ASSOCIATION: Work with your membership, aircraft
kit manufacturers, and avionics manufacturers to develop standards for the
recording of data in electronic flight displays, engine instruments, or other
recording devices to be used in support of flight tests or continued
airworthiness of experimental amateur-built aircraft.

TO
THE FEDERAL AVIATION ADMINISTRATION: Require the installation of a
crash-resistant flight recorder system on all newly manufactured
turbine-powered, nonexperimental, nonrestricted-category aircraft that are
not equipped with a flight data recorder and a cockpit voice recorder and are
operating under [Title] 14 Code of Federal Regulations Parts 91, 121, or 135. The crash-resistant flight recorder
system should record cockpit audio and images with a view of the cockpit
environment to include as much of the outside view as possible, and
parametric data per aircraft and system installation, all as specified in
Technical Standard Order C197, “Information Collection and Monitoring
Systems.”

TO
THE FEDERAL AVIATION ADMINISTRATION: Require all existing turbine-powered,
nonexperimental, nonrestricted-category aircraft that are not equipped with a
flight data recorder or cockpit voice recorder and are operating under
[title] 14 Code of Federal Regulations Parts 91, 121, or 135 to be retrofitted with a crash-resistant
flight recorder system. The crash-resistant flight recorder system should
record cockpit audio and images with a view of the cockpit environment to
include as much of the outside view as possible, and parametric data per
aircraft and system installation, all as specified in Technical Standard
Order C197, “Information Collection and Monitoring Systems.”

TO
THE FEDERAL AVIATION ADMINISTRATION: Require Boeing 787 operators to
incorporate guidance about the enhanced airborne flight recorder stale data
issue in their maintenance manuals to prevent stale data from being used for
maintenance activities or flight recorder maintenance.

TO
THE FEDERAL AVIATION ADMINISTRATION: Evaluate whether the recording of stale
data by the Boeing 787 enhanced airborne flight recorder, including whether
the data are specifically identified as stale, impacts the certification of
the recording system regarding the ranges, accuracies, and sampling intervals
specified in [Title] 14 Code of Federal Regulations Part 121 Appendix M, and take appropriate measures to correct
any problems found.

TO
THE FEDERAL AVIATION ADMINISTRATION: Require Boeing to improve the quality of
(1) the enhanced airborne flight recorder radio/hot microphone channels by
using the maximum available dynamic range of the individual channels and (2)
the cockpit area microphone airborne recordings by increasing the crew
conversation signals over the ambient background noise.

TO
THE FEDERAL AVIATION ADMINISTRATION: Require that all aircraft used in
extended overwater operations and operating under Title 14 Code
of Federal Regulations (1) Part 121 or (2) Part
135 that are required to have a cockpit voice recorder and a flight data
recorder, be equipped with a tamper-resistant method to broadcast to a ground
station sufficient information to establish the location where an aircraft terminates
flight as the result of an accident within 6 nautical miles of the point of
impact.

TO
THE FEDERAL AVIATION ADMINISTRATION: Require that all aircraft used in
extended overwater operations and operating under Title 14 Code of Federal
Regulations (1) Part 121 or (2) Part 135 that are required to have a cockpit
voice recorder and a flight data recorder, be equipped with an airframe low
frequency underwater locating device that will function for at least 90 days
and that can be detected by equipment available on military, search and
rescue, and salvage assets commonly used to search for and recover wreckage.

TO
THE FEDERAL AVIATION ADMINISTRATION: Require that all newly manufactured
aircraft used in extended overwater operations and operating under Title 14 Code of Federal Regulations (1) Part
121 or (2) Part 135 that are required to have a cockpit voice recorder and a
flight data recorder, be equipped with a means to recover, at a minimum,
mandatory flight data parameters; the means of recovery should not require
underwater retrieval. Data should be captured from a triggering event until
the end of the flight and for as long a time period before the triggering
event as possible.

TO
THE FEDERAL AVIATION ADMINISTRATION: Concurrent with the implementation of
Safety Recommendations A-15-1 and A-15-3, coordinate with other international
regulatory authorities and the International Civil Aviation Organization to
harmonize the implementation of the requirements outlined in Safety
Recommendations A-15-1 and A-15-3.

TO
THE FEDERAL AVIATION ADMINISTRATION: Require that all existing aircraft
operated under Title 14 Code of Federal Regulations (CFR)
Part 121 or 135 and currently required to have a cockpit voice recorder and a
flight data recorder be retrofitted with a crash-protected cockpit image
recording system compliant with Technical Standard Order TSO-C176a, “Cockpit
Image Recorder Equipment,” TSO-C176a or equivalent. The cockpit image
recorder should be equipped with an independent power source consistent with
that required for cockpit voice recorders in 14 CFR 25.1457. (Supersedes Safety Recommendation A-00-30)

TO
THE FEDERAL AVIATION ADMINISTRATION: Require that all newly manufactured
aircraft operated under Title 14 Code of Federal
Regulations (CFR) Part 121 or 135 and required to have a cockpit voice recorder
and a flight data recorder also be equipped with a crash-protected cockpit
image recording system compliant with Technical Standard Order TSO-C176a,
“Cockpit Image Recorder Equipment,” or equivalent. The cockpit image recorder
should be equipped with an independent power source consistent with that
required for cockpit voice recorders in 14 CFR 25.1457. (Supersedes Safety Recommendation A-00-31)

TO
THE FEDERAL AVIATION ADMINISTRATION: After the action in Safety
Recommendation A-16-34 is completed, require all [Title] 14 Code of Federal Regulations Part 135
operators to establish a structured flight data monitoring program that
reviews all available data sources to identify deviations from established
norms and procedures and other potential safety issues.

TO
THE FEDERAL AVIATION ADMINISTRATION: Review the problems with the quality of
the cockpit voice recorder (CVR) data in this accident to (1) determine why
the problems were not detected and corrected before the accident, despite the
requirements in Federal Aviation Administration Order 8900.1 and the guidance
in Safety Alert for Operators 06019, and (2) determine if the procedures in
Advisory Circular (AC) 20-186 would have ensured that the CVR problems were
identified and corrected before the accident, and if not, revise AC 20-186 to
ensure that such problems will be identified and corrected.

TO
THE INSTITUTE OF ELECTRICAL AND ELECTRONICS ENGINEERS AND THE SOCIETY OF
AUTOMATIVE ENGINEERS: Work together,
as part of your initiative to establish on-board vehicle recorder standards,
to develop standards for brake and transmission electronic control units that
require those units to store a full history of electronic fault codes that
are time stamped using a recognized clock synchronized with other on-board
event data recording devices.

TO
THE FEDERAL MOTOR CARRIER SAFETY ADMINISTRATION: Require all heavy commercial
vehicles to be equipped with video event recorders that capture data in
connection with the driver and the outside environment and roadway in the
event of a crash or sudden deceleration event. The device should create
recordings that are easily accessible for review when conducting efficiency
testing and systemwide performance-monitoring programs.

TO
THE FEDERAL MOTOR CARRIER SAFETY ADMINISTRATION: Require motor carriers to
review and use video event recorder information in conjunction with other
performance data to verify that driver actions are in accordance with company
and regulatory rules and procedures essential to safety.

TO
THE NATIONAL HIGHWAY TRAFFIC SAFETY ADMINISTRATION: Develop and implement
minimum performance standards for event data recorders for trucks with gross
vehicle weight ratings over 10,000 pounds that address, at a minimum, the
following elements: data parameters to be recorded; data sampling rates;
duration of recorded event; standardized or universal data imaging interface;
data storage format; and device and data survivability for crush, impact,
fluid exposure and immersion, and thermal exposure. The standards should also
require that the event data recorder be capable of capturing and preserving
data in the case of a power interruption or loss, and of accommodating future
requirements and technological advances, such as flashable and/or reprogrammable
operating system software and/or firmware updates.

TO
THE NATIONAL HIGHWAY TRAFFIC SAFETY ADMINISTRATION: After establishing
performance standards for event data recorders for trucks with gross vehicle
weight ratings over 10,000 pounds, require that all such vehicles be equipped
with event data recorders meeting the standards.

TO
THE AMERICAN BUS ASSOCIATION, UNITED MOTORCOACH ASSOCIATION, AMERICAN
TRUCKING ASSOCIATIONS, AMERICAN PUBLIC TRANSPORTATION ASSOCIATION, NATIONAL
ASSOCIATION FOR PUPIL TRANSPORTATION, NATIONAL ASSOCIATION OF STATE DIRECTORS
OF PUPIL TRANSPORTATION SERVICES, AND NATIONAL SCHOOL TRANSPORTATION
ASSOCIATION: Encourage your members to ensure that any onboard video system
in their vehicles provides visibility of the driver and of each occupant
seating location, visibility forward of the vehicle, optimized frame rate,
and low-light recording capability.

TO
THE UNITED STATES COAST GUARD: Require installation of voyage data recorders
that meet the International Maritime Organization’s performance standard for
voyage data recorders on new ferry vessels subject to [Title] 46 Code of Federal Regulations subchapters
H and K. (Supersedes Safety Recommendations M-10-005 through -006)

TO
THE UNITED STATES COAST GUARD: Develop a US voyage data recorder standard for
ferry vessels subject to [Title] 46 Code of Federal
Regulations subchapter T and require the
installation of such equipment where technically feasible. (Supersedes Safety
Recommendations M-10-005 through -006)

TO
THE MARYLAND TRANSIT ADMINISTRATION: Install, on all your light rail
vehicles, independent event recorders that record and retain the most recent
48 hours of data, store data in nonvolatile memory, and have a back-up power
source that would enable the entire recording system to function if electric
power is lost to the car.

TO
THE FEDERAL RAILROAD ADMINISTRATION: Require the installation, in all
controlling locomotive cabs and cab car operating compartments, of crash- and
fire-protected inward- and outward-facing audio and image recorders capable
of providing recordings to verify that train crew actions are in accordance
with rules and procedures that are essential to safety as well as train
operating conditions. The devices should have a minimum 12-hour continuous
recording capability with recordings that are easily accessible for review,
with appropriate limitations on public release, for the investigation of
accidents or for use by management in carrying out efficiency testing and
systemwide performance monitoring programs.

TO
THE FEDERAL RAILROAD ADMINISTRATION: Require that railroads regularly review
and use in-cab audio and image recordings (with appropriate limitations on
public release), in conjunction with other performance data, to verify that
train crew actions are in accordance with rules and procedures that are
essential to safety.

TO
THE ASSOCIATION OF AMERICAN RAILROADS: Develop a standard that specifies the
use of suitable crash-protected memory modules for all new and existing
installations of on-board video and audio recorders. The memory modules
should meet or exceed the survivability criteria specified in Title 49 Code of Federal Regulations 229.135
Appendix D, Table 2.

TO
THE FEDERAL RAILROAD ADMINISTRATION: Require all information captured by any
required recorder to also be recorded in another location remote from the
lead locomotive(s), to minimize the likelihood of the information’s being
unrecoverable as a result of an accident.

TO
ALL CLASS I RAILROADS: Install in all controlling locomotive cabs and cab car
operating compartments crash-and fire-protected inward-and outward-facing
audio and image recorders. The devices should have a minimum 12-hour
continuous recording capability.

TO
METRO NORTH RAILROAD: Require the installation, in all controlling locomotive
cabs and cab car operating compartments of crash-and fire-protected
inward-and outward-facing audio and image recorders capable of providing
recordings to verify that train crew actions are in accordance with rules and
procedures that are essential to safety as well as train operating
conditions. The devices should have a minimum 12-hour continuous recording
capability with recordings that are easily accessible for review, with
appropriate limitations on public release, for the investigation of accidents
or for use by management in carrying out efficiency testing and systemwide
performance monitoring programs.

TO
METRO NORTH RAILROAD: Regularly review and use in-cab audio and image
recordings in conjunction with other performance data, to verify that train
crew actions are in accordance with rules and procedures that are essential
to safety.

TO
THE NATIONAL RAILROAD PASSENGER CORPORATION (AMTRAK): Install, in all
controlling locomotive cabs and cab car operating compartments, crash-and
fire-protected inward-and outward-facing audio and image recorders capable of
providing recordings to verify that train crew actions are in accordance with
rules and procedures that are essential to safety as well as train operating
conditions. The devices should have a minimum 12-hour continuous recording
capability with recordings that are easily accessible for review, with
appropriate limitations on public release, for the investigation of accidents
or for use by management in carrying out efficiency testing and system wide
performance monitoring programs.

TO
THE NATIONAL RAILROAD PASSENGER CORPORATION (AMTRAK): Semi-annually, issue a
public report detailing Amtrak’s progress in installing crash-and
fire-protected inward-and outward-facing audio and image recorders. The
report should include the number of locomotives and cab car operating
compartments that have been equipped with the recorders, as well as the
number of locomotives and cab car operating compartments in Amtrak’s fleet
that still lack those devices.

TO
THE NATIONAL RAILROAD PASSENGER CORPORATION (AMTRAK): Regularly review and
use in-cab audio and image recordings in conjunction with other performance
data to verify crew member actions are in accordance with rules and
procedures that are essential to safety.

Prevent Loss of
Control in General Aviation

Rec #

Status

Text

Link

Requires
or possibly requires regulatory action

A-04-056

Open—Unacceptable Response

TO THE FEDERAL
AVIATION ADMINISTRATION: Modify
[Title] 14 Code of Federal Regulations Part 25 to include a certification standard that will ensure
safe handling qualities in the yaw axis throughout the flight envelope,
including limits for rudder pedal sensitivity.

TO
THE FEDERAL AVIATION ADMINISTRATION:
Develop a means to identify pilots whose overall performance history
indicates that they are at future risk of accident involvement, and develop a
program to reduce risk for those pilots.

TO
THE FEDERAL AVIATION ADMINISTRATION: Revise airman knowledge tests to include
questions regarding electronic flight and navigation displays, including
normal operations, limitations, and the interpretation of malfunctions and
aircraft attitudes.

TO
THE EXPERIMENTAL AIRCRAFT ASSOCIATION: Identify and apply incentives to
encourage owners, builders, and pilots of experimental amateur-built aircraft
to complete flight test training, such as that available in the Experimental
Aircraft Association’s Test Flying and Developing Pilot Operating Handbook,
prior to conducting flight tests of experimental amateur-built aircraft.

TO
THE EXPERIMENTAL AIRCRAFT ASSOCIATION: Complete planned action to create a
coalition of kit manufacturers, type clubs, and pilot and owner groups and
(1) develop transition training resources and (2) identify and apply
incentives to encourage both builders of experimental amateur-built aircraft
and purchasers of used experimental amateur-built aircraft to complete the
training that is developed.

TO
THE FEDERAL AVIATION ADMINISTRATION: Develop, in collaboration with your
internal offices that investigate aviation accidents and incidents and also
organizations familiar with the challenges facing pilots confronting an
emergency situation, and require recurrent national training for air traffic
controllers, including scenario-based training, to instruct them on
identifying and responding to emergency situations to include the following:

TO
THE FEDERAL AVIATION ADMINISTRATION:
In collaboration with your internal offices that investigate aviation
accidents and incidents and also organizations familiar with the challenges
facing pilots confronting an emergency situation, annually revise the
required training described in Safety Recommendation A-16-18 at the national
level to ensure that the training is current and relevant and includes
lessons learned from recent events throughout the National Airspace System
that address best practices for helping pilots who are experiencing problems
such as (but not limited to) the following:

Require Medical
Fitness​

Rec #

Status

Text

Link

Requires
or possibly requires regulatory action

A-04-047

Open—Acceptable Response

TO THE FEDERAL
AVIATION ADMINISTRATION: Based on the results of the research requested in
Safety Recommendation A-04-46, develop a standard battery of tests to be
performed at least once on each applicant for a Class 1 or 2 medical
certificate that would prevent applicants with color vision deficiencies that
could impair their ability to perform color-related critical aviation tasks
from being certificated without limitations.

TO
THE FEDERAL AVIATION ADMINISTRATION:
Require that all airmen clinically diagnosed with substance dependence
(including dependence on alcohol), as defined in [Title] 14
Code of Federal Regulations 67.107(a)(4)(ii),
67.207(a)(4)(ii), and 67.307(a)(4)(ii), who are medically certified by the
FAA subsequent to such diagnosis, are followed under guidelines for special
issuance of medical certificates for the period that they hold such
certificates.

TO
THE FEDERAL AVIATION ADMINISTRATION: Require pilots who are exempt from
medical certification requirements to periodically report to you their status
as an active pilot and to provide a summary of recent flight hours.

TO
THE FEDERAL AVIATION ADMINISTRATION: Restrict all pilots with medical
conditions that could affect their g-tolerance from performing aerobatic
maneuvers or air racing at events requiring a certificate of waiver or
authorization for an aviation event.

TO
THE FEDERAL AVIATION ADMINISTRATION: Develop and disseminate educational
information for pilots regarding the December 26, 2013, aircraft accident in
Fresno, California, and the risks cataracts may pose to flight safety
including a discussion of degraded vision at night, and encourage pilots with
cataracts to communicate with their eye care professionals regarding
diagnosis and treatment options.

TO
THE FEDERAL AVIATION ADMINISTRATION: Develop and disseminate educational
information for aviation medical examiners regarding the December 26, 2013,
aircraft accident in Fresno, California; the risks cataracts may pose to
flight safety including a discussion of degraded vision at night; and
referral of pilots with cataracts to eye care professionals.

TO
THE AIRCRAFT OWNERS AND PILOTS ASSOCIATION: Include in your educational
resources for pilots information about cataracts and the risks they pose to
flight safety including a discussion of degraded vision at night, and
encourage pilots with cataracts to communicate with their eye care
professionals regarding diagnosis and treatment options.

TO
THE FEDERAL MOTOR CARRIER SAFETY ADMINISTRATION: Develop a comprehensive
medical oversight program for interstate commercial drivers that contains the
following program elements: Medical
certification regulations are updated periodically to permit trained
examiners to clearly determine whether drivers with common medical conditions
should be issued a medical certificate.

TO
THE FEDERAL MOTOR CARRIER SAFETY ADMINISTRATION: Develop a comprehensive medical oversight
program for interstate commercial drivers that contains the following program
elements: Individuals performing
examinations have specific guidance and a readily identifiable source of
information for questions on such examinations.

TO
THE NATIONAL HIGHWAY TRAFFIC SAFETY ADMINISTRATION: In cooperation with the
American Medical Association and the American Association of Motor Vehicle
Administrators, develop a procedure to periodically collect, evaluate, and
report data, on a State and national basis, regarding the extent to which
medical conditions contribute to the cause of accidents.

TO
THE NATIONAL HIGHWAY TRAFFIC SAFETY ADMINISTRATION: In cooperation with the
American Association of Motor Vehicle Administrators: Determine the most
effective licensing countermeasures to reduce the risks posed by medically
impaired drivers.

TO
THE NATIONAL HIGHWAY TRAFFIC SAFETY ADMINISTRATION: Once the most effective reporting methods
and licensing countermeasures have been determined, develop a model
comprehensive medical oversight program for States to use to oversee
medically impaired drivers. Such a program should include, as a minimum:

a. Methods to provide information to the public on resource availability
and on the medical oversight laws and procedures to assist medically high-risk
drivers.
b. Plans and strategies to simplify and maximize reporting of potential
driver medical impairment to medical evaluation units of State driver
licensing organizations by law enforcement officers, health care providers,
emergency services providers, and the public.
c. Methods to capture all cases of motor vehicle incidents or accidents
potentially related to driver medical impairment.
d. Standardized methods of driver evaluation for potentially medically
impaired drivers incorporating medical records
review, systematic testing, and on-road appraisals, as needed.
e. Methods for timely and appropriate restriction of driving privileges for
drivers found to have medical conditions or treatments that impair their
ability to safely operate a motor vehicle.

TO
THE FEDERAL MOTOR CARRIER SAFETY ADMINISTRATION: Implement a program to
identify commercial drivers at high risk for obstructive sleep apnea and
require that those drivers provide evidence through the medical certification
process of having been appropriately evaluated and, if treatment is needed,
effectively treated for that disorder before being granted unrestricted
medical certification.

TO
THE FEDERAL MOTOR CARRIER SAFETY ADMINISTRATION: Develop and disseminate guidance for
commercial drivers, employers, and physicians regarding the identification
and treatment of individuals at high risk of obstructive sleep apnea (OSA),
emphasizing that drivers who have OSA that is effectively treated are
routinely approved for continued medical certification.

TO
THE NATIONAL SCHOOL TRANSPORTATION ASSOCIATION, THE NATIONAL ASSOCIATION FOR
PUPIL TRANSPORTATION, AND THE NATIONAL ASSOCIATION OF STATE DIRECTORS OF
PUPIL TRANSPORTATION SERVICES: Inform school bus drivers of the impact their
health may have on the safe transportation of school children, of their
responsibility to accurately and completely report their health history and
medications, and of the legal consequences of dishonesty on the medical
examination report.

TO
THE UNITED STATES COAST GUARD: Require
mariners to report to the Coast Guard, in a timely manner, any substantive
changes in their medical status or medication use that occur between required
medical evaluations. (Supersedes M-05-5)

TO
THE FEDERAL RAILROAD ADMINISTRATION: Develop, then periodically publish, an
easy-to-understand source of information for train operating crewmembers on
the hazards of using specific medications when performing their duties.

TO
THE FEDERAL TRANSIT ADMINISTRATION: Develop and disseminate guidance for
operators, transit authorities, and physicians regarding the identification
and treatment of individuals at high risk
for obstructive sleep apnea and
other sleep disorders.

TO
46 US RAIL TRANSIT AGENCIES: Review your medical history and physical
examination forms and modify them as necessary to ensure that they elicit
specific information about any previous diagnosis of obstructive sleep apnea
or other sleep disorders and about the presence of specific risk factors for
such disorders.

TO
46 US RAIL TRANSIT AGENCIES: Establish a program to identify operators who
are at high risk for obstructive sleep apnea or other sleep disorders and
require that such operators be appropriately
evaluated and treated.

TO
THE FEDERAL RAILROAD ADMINISTRATION: Determine what constitutes a reliable,
valid, and comparable field test procedure for assessing the color
discrimination capabilities of employees in safety-sensitive positions.

TO
THE FEDERAL RAILROAD ADMINISTRATION: When you have made the determination in
Safety Recommendation R-13-18, require railroads to use a reliable, valid,
and comparable field test procedure for assessing the color discrimination
capabilities of employees in safety-sensitive positions.

TO
THE FEDERAL RAILROAD ADMINISTRATION: Require more frequent medical
certification exams for employees in safety-sensitive positions who have
chronic conditions with the potential to deteriorate sufficiently to impair
safe job performance.

TO
THE FEDERAL RAILROAD ADMINISTRATION: Develop medical certification
regulations for employees in safety-sensitive positions that include, at a
minimum, (1) a complete medical history that includes specific screening for
sleep disorders, a review of current medications, and a thorough physical
examination, (2) standardization of testing protocols across the industry,
and (3) centralized oversight of certification decisions for employees who
fail initial testing; and consider requiring that medical examinations be
performed by those with specific training and certification in evaluating
medication use and health issues related to occupational safety on railroads.
(This recommendation supersedes Safety Recommendations R-02-24 through -26.)

TO
UNION PACIFIC: Replace your color vision field test with a test that has
established and acceptable levels of reliability, validity, and comparability
to ensure that certified employees in safety-sensitive positions have
sufficient color discrimination to perform safely.

TO
UNION PACIFIC: Until you have implemented a validated, reliable, and
comparable color vision field test, perform a safety analysis and undertake
measures to manage the risk created by the use of an inadequate test. Such
measures might include, but are not limited to, restricting crewmembers who
have failed primary color vision testing to yard assignments or unsignaled
territory.

TO
METRO-NORTH RAILROAD: Develop and implement protocols to routinely screen and
fully evaluate your safety-sensitive employees for sleep disorders and ensure
that such disorders are adequately addressed if diagnosed.

TO
THE LONG ISLAND RAILROAD: Develop and implement protocols to routinely screen
and fully evaluate your safety-sensitive employees for sleep disorders and
ensure that such disorders are adequately addressed, if diagnosed.

TO
THE ASSOCIATION OF AMERICAN RAILROADS, THE AMERICAN PUBLIC TRANSPORTATION
ASSOCIATION, THE AMERICAN SHORT LINE AND REGIONAL RAILROAD ASSOCIATION, THE
BROTHERHOOD OF LOCOMOTIVE ENGINEERS, AND THE INTERNATIONAL ASSOCIATION OF
SHEET METAL, AIR, RAIL AND TRANSPORTATION WORKERS: Collaborate to develop a
model national labor agreement that supports effective programs for
addressing sleep disorders and other medical conditions among
safety-sensitive train operating personnel.

TO
THE TO THE AMERICAN COLLEGE OF PHYSICIANS: Enhance initial and ongoing
training to ensure that Board-certified physicians in Internal Medicine can
successfully identify the risk factors for, evaluate, and effectively treat
obstructive sleep apnea among their patients.

TO
THE AMERICAN ACADEMY OF FAMILY PHYSICIANS: Enhance initial and ongoing
training to ensure that Board-certified physicians in Family Medicine can
successfully identify risk factors for, evaluate, and effectively treat
obstructive sleep apnea among their patients.

TO
THE FEDERAL RAILROAD ADMINISTRATION: Enhance your medical standards by
identifying a list of medical conditions that disqualify employees for
safety-sensitive positions because of the conditions’ potential for
negatively affecting rail safety.

TO
THE FEDERAL RAILROAD ADMINISTRATION: Enhance your medical standards by
identifying a list of medical conditions that disqualify employees for
safety-sensitive positions because of the conditions’ potential for
negatively affecting rail safety.

TO
THE FEDERAL RAILROAD ADMINISTRATION: Once disqualifying medical conditions
and medications have been identified, develop specific criteria (such as
standards for medical test results) that may allow employees who have been
disqualified but have been determined by a subsequent, individualized
assessment to pose no increased danger to rail safety to obtain a medical
certification.

TO
THE FEDERAL RAILROAD ADMINISTRATION: Develop and enforce medical standards
that railroad employees in safety-sensitive positions diagnosed with sleep
disorders must meet to be considered fit for duty.

TO
BNSF RAILWAY, CANADIAN NATIONAL RAILWAY, CANADIAN PACIFIC RAILWAY, CSX
TRANSPORTATION, KANSAS CITY SOUTHERN RAILWAY, NORFOLK SOUTHERN RAILWAY,
INTERCITY RAILROADS, AND COMMUTER RAILROADS: Review and revise as necessary
your medical rules, standards, or protocols to ensure you are informed of any
diagnosed sleep disorders that employees in safety-sensitive positions must
report and, when an employee makes such a report, perform periodic
evaluations to ensure the condition is appropriately treated and the employee
is fit for duty.

TO
UNION PACIFIC RAILROAD: Revise your medical rules to add any diagnosed sleep
disorder to the list of medical conditions that employees in safety-sensitive
positions must report and, when an employee makes such a report, perform
periodic evaluations to ensure the condition is appropriately treated and the
employee is fit for duty.

Improve Rail
Transit Safety Oversight

Rec #

Status

Text

Link

Requires
or possibly requires regulatory action

R-06-003

Open—Acceptable Response

TO THE FEDERAL
TRANSIT ADMINISTRATION: Require transit agencies, through the system safety
program and hazard management process if necessary, to ensure that the time
off between daily tours of duty, including regular and overtime assignments,
allows train operators to obtain at least 8 hours of uninterrupted sleep.

TO
THE FEDERAL TRANSIT ADMINISTRATION: Advise all rail transit operators that
have train control systems capable of monitoring train movements to determine
whether their systems have adequate safety redundancy if losses in train
detection occur. If a system is susceptible to single point failures, urge
and verify that corrective action is taken to add redundancy by evaluating
track occupancy data on a real-time basis to automatically generate alerts
and speed restrictions to prevent train collisions. (Urgent)

TO
46 US RAIL TRANSIT AGENCIES: Review your medical history and physical
examination forms and modify them as necessary to ensure that they elicit
specific information about any previous diagnosis of obstructive sleep apnea
or other sleep disorders and about the presence of specific risk factors for
such disorders.

TO
46 US RAIL TRANSIT AGENCIES: Establish a program to identify operators who
are at high risk for obstructive sleep apnea or other sleep disorders and
require that such operators be appropriately
evaluated and treated.

TO
THE FEDERAL TRANSIT ADMINISTRATION:
Seek authority similar to Federal Railroad Administration regulations
(Title 49 Code of Federal Regulations [Part] 219.207) to require that transit agencies obtain
toxicological specimens from covered transit employees and contractors who
are fatally injured as a result of an on-duty accident.

TO
THE 50 STATES AND THE DISTRICT OF COLUMBIA: Obtain the statutory authority to
provide safety oversight of all fixed guideway transportation systems that
operate within your jurisdiction, regardless of their funding authorization
or the date they began operation.

TO
THE FEDERAL TRANSIT ADMINISTRATION: Once the action specified in Safety
Recommendation R-14-38 is completed, update the state safety oversight
program to ensure that rail transit systems are meeting the safety
requirements for roadway workers.

TO
METRO-NORTH RAILROAD: Require, as part of your risk management program, that
representatives from all your divisions and labor organizations (1) regularly
review safety and operational data from all divisions to identify safety
issues and trends and (2) share the results across divisions.

TO
METRO-NORTH RAILROAD: Develop and implement a robust internal audit and
oversight program, in coordination with your safety risk management process,
to ensure that all employees and managers comply with your established safety
procedures.

TO
THE METROPOLITAN TRANSPORTATION AUTHORITY: Require representatives from your
operating divisions to regularly review safety and operational data from all
divisions to identify safety issues and trends and share the results across
your operating properties.

TO
THE METROPOLITAN TRANSPORTATION AUTHORITY: Establish a program to
systematically evaluate deficiencies identified on one Metropolitan
Transportation Authority property, and determine the applicability of safety
mitigations to other Metropolitan Transportation Authority properties.

TO
THE METROPOLITAN TRANSPORTATION AUTHORITY: Develop an oversight and tracking
process to ensure that the recommendations from the various investigations
and reviews of Metro-North Railroad are coordinated, addressed, and resolved
at all Metropolitan Transportation Authority properties.

TO
THE FEDERAL TRANSIT ADMINISTRATION: Develop a work scheduling program for
rail transit agencies that incorporates fatigue science—such as validated
biomathematical models of fatigue—and provides for the management of
personnel fatigue risks, and implement the program through the state safety
oversight program.

TO
THE FEDERAL TRANSIT ADMINISTRATION: Establish (through the state safety
oversight program) scientifically based hours-of-service regulations that set
limits on hours of service, provide predictable work and rest schedules, and
consider circadian rhythms and human sleep and rest requirements.

TO
THE FEDERAL TRANSIT ADMINISTRATION: Identify the necessary training and
certification needs for work schedulers in the rail transit industry and
require the transit agencies—through the state safety oversight program—to
provide additional training or certification for their work schedulers.

TO
THE FEDERAL TRANSIT ADMINISTRATION: Require (through the state safety
oversight program) rail transit employees who develop work schedules to
complete initial and recurrent training based on current fatigue science to
identify and mitigate work schedule risks that contribute to operator
fatigue.

TO
THE UNITED STATES DEPARTMENT OF TRANSPORTATION: Seek an amendment to Title 45
United States Code section
1104(3) to list the Washington Metropolitan Area Transit Authority as a
commuter authority, thus authorizing the Federal Railroad Administration to
exercise regulatory oversight of the Washington Metropolitan Area Transit
Authority’s rail system. (Urgent)

TO
THE UNITED STATES DEPARTMENT OF TRANSPORTATION: After Title 45 United States Code section 1104(3)
is amended to include the Washington Metropolitan Area Transit Authority,
direct the Administrator of the Federal Railroad Administration to develop
and implement a plan to transition the oversight of the Washington
Metropolitan Area Transit Authority’s rail system to the Federal Railroad
Administration within 6 months. (Urgent)

TO
THE FEDERAL TRANSIT ADMINISTRATION: Utilize your authority under Title 49 Code of Federal Regulations 670.25,
and issue a general directive that would require all state safety oversight
agencies to direct rail transit agencies to periodically test the performance
of all of their rail transit vehicle braking systems to detect potential
latent system failures.

Eliminate
Distractions

Rec #

Status

Text

Link

Requires
or possibly requires regulatory action

A-13-014

Open—Acceptable Response

TO AIR METHODS
CORPORATION: Expand your policy on portable electronic devices to prohibit
their nonoperational use during safety-critical ground activities, such as
flight planning and preflight inspection, as well as in flight.

TO
THE NATIONAL HIGHWAY TRAFFIC SAFETY ADMINISTRATION: Determine the magnitude
and impact of driver-controlled, in-vehicle distractions, including the use
of interactive wireless communication devices, on highway safety and report
your findings to the US Congress and the States.

TO
6 MOTORCOACH INDUSTRY, PUBLIC BUS, AND SCHOOL BUS ASSOCIATIONS AND 3 UNIONS:
Develop formal policies prohibiting cellular telephone use by commercial
driver’s license holders with a passenger-carrying or school bus endorsement,
while driving under the authority of that endorsement, except in emergencies.

TO
THE 50 STATES AND THE DISTRICT OF COLUMBIA: (1) Ban the nonemergency use of
portable electronic devices (other than those designed to support the driving
task) for all drivers; (2) use the National Highway Traffic Safety
Administration model of high visibility enforcement to support these bans;
and (3) implement targeted communication campaigns to inform motorists of the
new law and enforcement, and to warn them of the dangers associated with the
nonemergency use of portable electronic devices while driving.

TO
CTIA-THE WIRELESS ASSOCIATION AND THE CONSUMER ELECTRONICS ASSOCIATION:
Encourage the development of technology features that disable the functions
of portable electronic devices within reach of the driver when a vehicle is
in motion; these technology features should include the ability to permit
emergency use of the device while the vehicle is in motion and have the
capability of identifying occupant seating position so as not to interfere
with use of the device by passengers.

TO
THE FIFTY STATES, THE DISTRICT OF COLUMBIA, AND THE COMMONWEALTH OF PUERTO
RICO: Ban the nonemergency use by pilot/escort vehicle drivers of portable
electronic devices (other than those designed to support the pilot/escort
vehicle driving task), except to communicate hazard-related information to
the escorted vehicle.

TO
THE FEDERAL MOTOR CARRIER SAFETY ADMINISTRATION: Modify Title 49 Code of Federal Regulations Part
392.82 to prohibit any use of a hands-free portable electronic device by a
commercial driver’s license holder while the driver is operating a commercial
vehicle, except in emergencies.

TO
THE UNITED STATES COAST GUARD: Distribute a safety alert on amphibious
passenger vehicle operations that addresses the role of risk assessment to
mitigate driver distraction, as well as the need to tell passengers to remove
seat belts before waterborne operations begin.

TO
THE PASSENGER VESSEL ASSOCIATION: Notify all your amphibious passenger
vehicle (APV) operator members of the importance of the following: (1)
learning the lessons from the Seattle, Washington, and Boston, Massachusetts,
crashes; (2) completing proper maintenance and service bulletin repairs; (3)
using the pretrip safety orientation to tell passengers of APVs equipped with
passenger seat belts to unbuckle their belts before the APV begins any marine
operations; (4) conducting a visual inspection to ensure that passengers have
unbuckled their seat belts prior to water entry; (5) reducing the risk of
driver distraction by having a tour guide conduct each tour; (6) managing
risk in tour operations by addressing such factors as driver distraction,
route planning, vehicle characteristics, traffic density, and vehicle speed;
and (7) conducting operations according to Navigation and Vessel Inspection
Circular 1-01 guidance and US Coast Guard safety alerts.

TO
THE FEDERAL RAILROAD ADMINISTRATION: Identify, and require railroads to use
in locomotive cabs, technology-based solutions that detect the presence of
signal-emitting portable electronic devices and that inform the railroad
management about the detected devices in real time.

End Alcohol and
Other Drug Impairment in Transportation

Rec #

Status

Text

Link

Requires
or possibly requires regulatory action

A-07-043

Open—Acceptable Response

TO THE FEDERAL
AVIATION ADMINISTRATION: Require that
all airmen clinically diagnosed with substance dependence (including
dependence on alcohol), as defined in [Title] 14 Code of
Federal Regulations 67.107(a)(4)(ii),
67.207(a)(4)(ii), and 67.307(a)(4)(ii), who are medically certified by the
FAA subsequent to such diagnosis, are followed under guidelines for special
issuance of medical certificates for the period that they hold such
certificates.

TO
THE FEDERAL AVIATION ADMINISTRATION: Develop, publicize, and periodically
update information to educate pilots about the potentially impairing drugs
identified in your toxicology test results of fatally injured pilots, and
make pilots aware of less impairing alternative drugs if they are available.

TO
THE FEDERAL AVIATION ADMINISTRATION: Require pilots who are exempt from
medical certification requirements to periodically report to you their status
as an active pilot and to provide a summary of recent flight hours.

TO
THE FEDERAL AVIATION ADMINISTRATION: Conduct a study to assess the prevalence
of over-the-counter, prescription, and illicit drug use among flying pilots
not involved in accidents, and compare those results with findings from
pilots who have died from aviation accidents to assess the safety risks of
using those drugs while flying.

TO
THE STATES AND THE DISTRICT OF COLUMBIA CHILD CARE TRANSPORTATION OVERSIGHT
AGENCIES: Implement an oversight
program for child care transportation that includes the following elements: Review by an oversight agency of periodic
driver background checks, medical examinations, and drug test results.

TO
THE NATIONAL ASSOCIATION FOR THE EDUCATION OF YOUNG CHILDREN: As part of your accreditation program,
establish a transportation safety accreditation that requires applicants to
implement the following elements:

Use of vehicles built to school bus standards or of multifunction school
activity buses;

A regular vehicle maintenance and inspection program;

A requirement that occupants wear age-appropriate restraints at all times;

A requirement that drivers receive a criminal background check and have a
medical examination to determine fitness to drive;

Preemployment, random, postaccident, and "for cause" drug testing
for all child care transportation providers and the prohibition of anyone who
tests positive for drugs from transporting children;

TO
ARROW STAGE LINES: Develop written contingency plans for each charter to
ensure that trip planning is in place in the event of driver fatigue,
incapacitation, or illness or in the event of trip delays necessitating
replacement drivers to avoid hours-of-service violations and inform drivers
of their trip’s contingency plans.

TO
THE NATIONAL HIGHWAY TRAFFIC SAFETY ADMINISTRATION: Develop and disseminate
to the 50 states, the Commonwealth of Puerto Rico, and the District of
Columbia blood alcohol concentration testing and reporting guidelines based
on the 2012 report State Blood Alcohol Concentration Testing and Reporting
for Drivers Involved in Fatal Crashes: Current Practices, Results, and
Strategies, 1997–2009.

TO
THE NATIONAL HIGHWAY TRAFFIC SAFETY ADMINISTRATION: Develop and disseminate
to appropriate state officials a common standard of practice for drug
toxicology testing, including (1) the circumstances under which tests should
be conducted, (2) a minimum set of drugs for which to test, and (3) cutoff
values for reporting the results.

TO
THE 45 STATES, THE COMMONWEALTH OF PUERTO RICO, AND THE DISTRICT OF COLUMBIA,
WHICH HAVE LOW REPORTING RATES FOR BAC TESTING: Increase your collection,
documentation, and reporting of blood alcohol concentration (BAC) test
results by taking the following actions, as needed, to improve testing and
reporting rates: (1) enact legislation, (2) issue regulations, and (3)
improve procedures used by law enforcement agencies or testing facilities.

TO
THE 45 STATES, THE COMMONWEALTH OF PUERTO RICO, AND THE DISTRICT OF COLUMBIA,
WHICH HAVE LOW REPORTING RATES FOR BAC TESTING: Once the National Highway
Traffic Safety Administration has developed the blood alcohol concentration
(BAC) testing and reporting guidelines recommended in Safety Recommendation
H-12-32, incorporate the guidelines into a statewide action plan to achieve
BAC reporting rates of at least 80 percent of fatally injured drivers and at
least 60 percent of drivers who survived fatal crashes.

TO
THE 50 STATES, THE COMMONWEALTH OF PUERTO RICO, AND THE DISTRICT OF COLUMBIA:
Require law enforcement agencies to collect place of last drink (POLD) data
as part of any arrest or accident investigation involving an alcohol-impaired
driver.

TO
THE INTERNATIONAL ASSOCIATION OF CHIEFS OF POLICE AND THE NATIONAL SHERIFFS’
ASSOCIATION: Inform your members of the value of collecting place of last
drink (POLD) data as part of any arrest or accident investigation involving
an alcohol-impaired driver.

TO
THE NATIONAL HIGHWAY TRAFFIC SAFETY ADMINISTRATION: Work with the Automotive
Coalition for Traffic Safety, Inc., to accelerate widespread implementation
of Driver Alcohol Detection System for Safety (DADSS) technology by (1)
defining usability testing that will guide driver interface design and (2)
implementing a communication program that will direct driver education and
promote public acceptance.

TO
33 STATES, THE COMMONWEALTH OF PUERTO RICO, AND THE DISTRICT OF COLUMBIA:
Enact laws to require the use of alcohol ignition interlock devices for all
individuals convicted of driving while intoxicated (DWI) offenses.

TO
THE AUTOMOTIVE COALITION FOR TRAFFIC SAFETY: Work with the National Highway
Traffic Safety Administration to accelerate widespread implementation of
Driver Alcohol Detection System for Safety (DADSS) technology by (1) defining
usability testing that will guide driver interface design and (2)
implementing a communication program that will direct driver education and
promote public acceptance.

TO
THE NATIONAL HIGHWAY TRAFFIC SAFETY ADMINISTRATION: Seek legislative
authority to award incentive grants for states to establish a per se blood
alcohol concentration (BAC) limit of 0.05 or lower for all drivers who are
not already required to adhere to lower BAC limits.

TO
THE 50 US STATES AND THE COMMONWEALTH OF PUERTO RICO AND THE DISTRICT OF
COLUMBIA: Establish a per se blood alcohol concentration (BAC) limit of 0.05
or lower for all drivers who are not already required to adhere to lower BAC
limits.

TO
THE 50 STATES, THE COMMONWEALTH OF PUERTO RICO AND THE DISTRICT OF COLUMBIA:
Include in your impaired driving prevention plan or highway safety plan
provisions for conducting high-visibility enforcement of impaired driving
laws using passive alcohol-sensing technology during law enforcement
contacts, such as routine traffic stops, saturation patrols, sobriety
checkpoints, and accident scene responses.

TO
THE 50 STATES, THE COMMONWEALTH OF PUERTO RICO, AND THE DISTRICT OF COLUMBIA:
Include in your impaired driving prevention plan or highway safety plan
elements to target repeat offenders and reduce driving while intoxicated
(DWI) recidivism; such elements should include measures to improve compliance
with alcohol ignition interlock requirements; the plan should also provide a
mechanism for regularly assessing the success of these efforts. [This recommendation supersedes Safety
Recommendation H-00-26.]

TO
THE 50 STATES, THE COMMONWEALTH OF PUERTO RICO, AND THE DISTRICT OF COLUMBIA:
Take the following steps to move toward zero deaths from impaired driving:
(1) set specific and measurable targets for reducing impaired driving
fatalities and injuries, (2) list these targets in your impaired driving
prevention plan or highway safety plan, and (3) provide a mechanism for
regularly assessing the success of implemented countermeasures and
determining whether the targets have been met.

TO
THE 41 STATES THAT HAVE ADMINISTRATIVE LICENSE SUSPENSION OR REVOCATION LAWS
AND THE DISTRICT OF COLUMBIA: Incorporate into your administrative license
suspension or revocation laws a requirement that drivers arrested for driving
while intoxicated (DWI) use an alcohol ignition interlock on their vehicle
for a period of time before obtaining full license reinstatement.

TO
THE 10 STATES THAT DO NOT HAVE ADMINISTRATIVE LICENSE SUSPENSION OR
REVOCATION LAWS AND THE COMMONWEALTH OF PUERTO RICO: Establish administrative
license suspension or revocation laws that require drivers arrested for
driving while intoxicated (DWI) to use an alcohol ignition interlock on their
vehicle for a period of time before obtaining full license
reinstatement.

TO
THE FEDERAL MOTOR CARRIER SAFETY ADMINISTRATION: Determine the prevalence of
commercial motor vehicle driver use of impairing substances, particularly
synthetic cannabinoids, and develop a plan to reduce the use of such
substances.

TO
THE FEDERAL MOTOR CARRIER SAFETY ADMINISTRATION: Work with motor carrier
industry stakeholders to develop a plan to aid motor carriers in addressing
commercial motor vehicle driver use of impairing substances, particularly
those not covered under current drug-testing regulations such as by promoting
best practices by carriers, expanding impairment detection training and
authority, and developing performance-based methods of evaluation.

TO
AMERICAN BUS ASSOCIATION, AMERICAN TRUCKING ASSOCIATIONS, COMMERCIAL VEHICLE
SAFETY ALLIANCE, OWNER-OPERATOR INDEPENDENT DRIVERS ASSOCIATION, UNITED
MOTORCOACH ASSOCIATION: Inform your members about the dangers of driver use
of synthetic drugs and encourage them to take steps to prevent drivers from
using these substances.

TO
THE FEDERAL MOTOR CARRIER SAFETY ADMINISTRATION: Disseminate information to
motor carriers about using hair testing as a method of detecting the use of
controlled substances, under the appropriate circumstances.

TO
THE FIFTY STATES, THE DISTRICT OF COLUMBIA, AND THE COMMONWEALTH OF PUERTO
RICO: Include in all state guidelines regarding prescribing controlled
substances for pain a recommendation that health care providers discuss with
patients the effect their medical condition and medication use may have on
their ability to safely operate a vehicle in any mode of transportation.

TO
THE FIFTY STATES, THE DISTRICT OF COLUMBIA, AND THE COMMONWEALTH OF PUERTO
RICO: Use existing newsletters or other routine forms of communication with
licensed health care providers and pharmacists to highlight the importance of
routinely discussing with patients the effect their diagnosed medical
conditions or recommended drugs may have on their ability to safely operate a
vehicle in any mode of transportation.

TO
THE UNITED STATES COAST GUARD: Align your standards for postaccident
toxicological testing of Coast Guard military personnel with the requirements
specified in [Title] 46 Code of Federal Regulations 4.06-3.

TO
THE UNITED STATES COAST GUARD: Disseminate guidance within the Coast Guard so
that commanding officers have unambiguous instruction detailing the
requirements for timely drug and alcohol testing of Coast Guard military and
civilian personnel whose work performance may be linked to a serious marine
incident.

TO
THE PIPELINE AND HAZARDOUS MATERIALS SAFETY ADMINISTRATION: Amend Title 49 Code of Federal Regulations 199.105
and [Title] 49 Code of Federal Regulations 199.225 to eliminate operator discretion with regard to
testing of covered employees. The revised language should require drug and
alcohol testing of each employee whose performance either contributed to the
accident or cannot be completely discounted as a contributing factor to the
accident.

TO
THE FEDERAL RAILROAD ADMINISTRATION:
Develop, then periodically publish, an easy-to-understand source of
information for train operating crewmembers on the hazards of using specific
medications when performing their duties.

TO
THE FEDERAL RAILROAD ADMINISTRATION: Establish and implement an educational
program targeting train operating crewmembers that, at a minimum, ensures
that all crewmembers are aware of the source of information described in
R-00-2 regarding the hazards of using specific medications when performing
their duties.

TO
THE FEDERAL RAILROAD ADMINISTRATION:
Establish, in coordination with the US Dept. of Transportation, the
Federal Motor Carrier Safety Administration, the Federal Transit
Administration, and the US Coast Guard, comprehensive toxicological testing
requirements for an appropriate sample of fatal highway, railroad, transit,
and marine accidents to ensure the identification of the role played by
common prescription and over-the-counter medications. Review and analyze the results of such
testing at intervals not to exceed every 5 years.

TO
THE FEDERAL RAILROAD ADMINISTRATION:
Modify [Title] 49 Code of Federal Regulations 219.201(b) as necessary to ensure that the exemption from
mandatory postaccident drug and alcohol testing for those involved in
highway-rail grade crossing accidents does not apply to any railroad signal,
maintenance, and other employees whose actions at or near a grade crossing
involved in an accident may have contributed to the occurrence or severity of
the accident.

TO
THE FEDERAL RAILROAD ADMINISTRATION:
Revise the definition of covered employee under [Title] 49 Code of Federal Regulations Part 219
for purposes of Congressionally mandated alcohol and controlled substances
testing programs to encompass all employees and agents performing
safety-sensitive functions, as described in [Title] 49 Code of Federal Regulations 209.301
and 209.303.

TO
THE FEDERAL TRANSIT ADMINISTRATION:
Seek authority similar to Federal Railroad Administration regulations
(Title 49 Code of Federal Regulations 219.207) to require that transit agencies obtain toxicological
specimens from covered transit employees and contractors who are fatally
injured as a result of an on-duty accident.

TO
THE FEDERAL RAILROAD ADMINISTRATION: Develop medical certification
regulations for employees in safety-sensitive positions that include, at a
minimum, (1) a complete medical history that includes specific screening for
sleep disorders, a review of current medications, and a thorough physical
examination, (2) standardization of testing protocols across the industry,
and (3) centralized oversight of certification decisions for employees who
fail initial testing; and consider requiring that medical examinations be
performed by those with specific training and certification in evaluating
medication use and health issues related to occupational safety on railroads.
[This recommendation supersedes Safety Recommendations R-02-24 through -26.]

Ensure the Safe Shipment of Hazardous Materials

Rec #

Status

Text

Link

Requires
or possibly requires regulatory action

A-08-001

Open—Acceptable Response

TO THE FEDERAL
AVIATION ADMINISTRATION AND THE HAZARDOUS MATERIALS SAFETY ADMINISTRATION: In
collaboration with air carriers, manufacturers of lithium batteries and
electronic devices, air travel associations, and other appropriate government
and private organizations, establish a process to ensure wider, highly
visible, and continuous dissemination of guidance and information to the
air-traveling public, including flight crews, about the safe carriage of
secondary (rechargeable) lithium batteries or electronic devices containing
these batteries on board passenger aircraft.

TO
THE FEDERAL AVIATION ADMINISTRATION AND THE HAZARDOUS MATERIALS SAFETY
ADMINISTRATION: In collaboration with air carriers, manufacturers of lithium
batteries and electronic devices, air travel associations, and other
appropriate government and private organizations, establish a process to
periodically measure the effectiveness of your efforts to educate the
air-traveling public, including flight crews, about the safe carriage of
secondary (rechargeable) lithium batteries or electronic devices containing
these batteries on board passenger aircraft.

TO
THE FEDERAL AVIATION ADMINISTRATION: Develop fire detection system
performance requirements for the early detection of fires originating within
cargo containers and pallets and, once developed, implement the new
requirements. (This safety recommendation supersedes Safety Recommendation
A-07-98)

TO
THE FEDERAL AVIATION ADMINISTRATION: Require the installation and use of
active fire suppression systems in all aircraft cargo compartments or
containers, or both, such that fires are not allowed to develop.

TO
THE PIPELINE AND HAZARDOUS MATERIALS SAFETY ADMINISTATION: Require that Class
3 flammable liquids and fully regulated Class 9 lithium batteries be
physically segregated when stowed on board an aircraft such that packages
containing these materials may not be placed on the same or adjacent pallets
or ULDs.

TO
THE PIPELINE AND HAZARDOUS MATERIALS SAFETY ADMINISTATION: Establish maximum
loading density requirements that restrict the quantities of Class 3
flammable hazardous materials or Class 9 lithium batteries stowed on a single
pallet or ULD, or on a group of pallets or ULDs, within an aircraft such that
cargo fires can be effectively managed by on-board fire suppression
capabilities.

TO
THE FEDERAL RAILROAD ADMINISTRATION:
Modify [Title] 49 Code of Federal Regulations [Part] 219.201(b) as necessary to ensure that the exemption
from mandatory postaccident drug and alcohol testing for those involved in
highway-rail grade crossing accidents does not apply to any railroad signal,
maintenance, and other employees whose actions at or near a grade crossing
involved in an accident may have contributed to the occurrence or severity of
the accident.

TO
THE FEDERAL RAILROAD ADMINISTRATION:
Develop and implement tank car design-specific fracture toughness
standards, such as a minimum average Charpy value, for steels and other
materials of construction for pressure tank cars used for the transportation
of U.S. Department of Transportation class 2 hazardous materials, including
those in "low temperature" service. The performance criteria must
apply to the material orientation with the minimum impact resistance and take
into account the entire range of operating temperatures of the tank car.

TO
THE FEDERAL RAILROAD ADMINISTRATION: Assist the Pipeline and Hazardous
Materials Safety Administration in developing regulations to require that
railroads immediately provide to emergency responders accurate, real-time
information regarding the identity and location of all hazardous materials on
a train.

TO
THE PIPELINE AND HAZARDOUS MATERIALS SAFETY ADMINISTRATION: Require that all
newly manufactured and existing tank cars authorized for transportation of
hazardous materials have center sill or draft sill attachment designs that
conform to the revised Association of American Railroads’ design requirements
adopted as a result of Safety Recommendation R-12-9.

TO
THE FEDERAL RAILROAD ADMINISTRATION: Develop a program to audit response
plans for rail carriers of petroleum products to ensure that adequate
provisions are in place to respond to and remove a worst-case discharge to
the maximum extent practicable and to mitigate or prevent a substantial
threat of a worst-case discharge.

TO
THE PIPELINE AND HAZARDOUS MATERIALS SAFETY ADMINISTRATION: Require shippers
to sufficiently test and document the physical and chemical characteristics
of hazardous materials to ensure the proper classification, packaging, and
record-keeping of products offered in transportation.

TO
THE FEDERAL RAILROAD ADMINISTRATION: Collaborate with the Pipeline and
Hazardous Materials Safety Administration and the American Short Line and
Regional Railroad Association to develop a risk assessment tool that
addresses the known limitations and shortcomings of the Rail Corridor Risk
Management Safety software tool.

TO
THE FEDERAL RAILROAD ADMINISTRATION: Collaborate with the Pipeline and
Hazardous Materials Safety Administration and the American Short Line and
Regional Railroad Association to conduct audits of short line and regional
railroads to ensure that proper route risk assessments that identify safety
and security vulnerabilities are being performed and are incorporated into a
safety management system program.

TO
THE PIPELINE AND HAZARDOUS MATERIALS SAFETY ADMINISTRATION: Establish a
publicly available reporting mechanism that reports, at least annually,
progress on retrofitting and replacing tank cars subject to thermal
protection system performance standards as recommended in safety
recommendation R-15-16. (Urgent)

TO
THE PIPELINE AND HAZARDOUS MATERIALS SAFETY ADMINISTRATION: Evaluate the
risks posed to train crews by hazardous materials transported by rail,
determine the adequate separation distance between hazardous materials cars
and locomotives and occupied equipment that ensures the protection of train
crews during both normal operations and accident conditions, and collaborate
with the Federal Railroad Administration to revise [Title] 49 Code of Federal Regulations [Part]
174.85 to reflect those findings.

TO
THE PIPELINE AND HAZARDOUS MATERIALS SAFETY ADMINISTRATION: Pending
completion of the risk evaluation and action in accordance with its findings
prescribed in Safety Recommendation R-17-01, withdraw regulatory
interpretation 06-0278 that pertains to [Title] 49 Code
of Federal Regulations [Part] 174.85 for
positioning placarded rail cars in a train and require that all trains have a
minimum of five nonplacarded cars between any locomotive or occupied
equipment and the nearest placarded car transporting hazardous materials,
regardless of train length and consist.

TO
THE FEDERAL RAILROAD ADMINISTRATION: Evaluate the risks posed to train crews
by hazardous materials transported by rail, determine the adequate separation
distance between hazardous materials cars and locomotives and occupied
equipment that ensures the protection of train crews during both normal
operations and accident conditions, and collaborate with the Pipeline and
Hazardous Materials Safety Administration to revise [Title] 49 Code of Federal Regulations [Part]
174.85 to reflect those findings.

TO
THE PIPELINE AND HAZARDOUS MATERIALS SAFETY ADMINISTRATION: Include the
increased derailment risks associated with Class 1 track, the relationship
between the weight of the railcars and the weight of the rail, and the
potential failure of legacy US Department of Transportation-111 tank cars
during derailments in the list of items for railroads to consider when
determining the routes for high-hazard flammable trains or high-hazard
flammable unit trains, as found in appendix D of Title 49 Code
of Federal Regulations Part 172.

TO THE PIPELINE AND HAZARDOUS MATERIALS SAFETY ADMINISTRATION AND THE FEDERAL RAILROAD ADMINISTRATION: Work together to develop specific guidance for
railroads when using the list of items found in appendix D of Title 49 Code of Federal Regulations Part 172
in their risk assessments and apply the information gathered in those risk
assessments when analyzing proposed routes for high-hazard flammable trains
or high-hazard flammable unit trains.

TO
THE NATIONAL HIGHWAY TRAFFIC SAFETY ADMINISTRATION: Once minimum performance
standards for connected
vehicle technology are developed, require this technology to
be installed on all newly manufactured highway vehicles.

TO
THE NATIONAL HIGHWAY TRAFFIC SAFETY ADMINISTRATION: Develop and apply testing
protocols to assess the performance of forward collision avoidance systems in
passenger vehicles at various velocities, including high speed and high
velocity-differential.

TO
THE NATIONAL HIGHWAY TRAFFIC SAFETY ADMINISTRATION: Complete, as soon as
possible, the development and application of performance standards and
protocols for the assessment of forward collision avoidance systems in
commercial vehicles. (Safety Recommendation H-15-005 supersedes Safety
Recommendation H-01-006)

TO
THE NATIONAL HIGHWAY TRAFFIC SAFETY ADMINISTRATION: Once the rating scale
described in Safety Recommendation H-15-6 is established, include the ratings
of forward collision avoidance systems on the vehicle Monroney labels.

TO
PASSENGER VEHICLE, TRUCK-TRACTOR, MOTORCOACH, AND SINGLE-UNIT TRUCK
MANUFACTURERS: Install forward collision avoidance systems that include, at a
minimum, a forward collision warning component as standard equipment on all
new vehicles.

TO
GOOGLE, APPLE, GARMIN LTD., HERE, TOMTOM NV, INRIX, MAPQUEST, MICROSOFT
CORPORATION, OMNITRACS LLC, OPENSTREETMAP US, SENSYS NETWORKS, STREETLIGHT
DATA INC., TELETRAC, INC., AND UNITED PARCEL SERVICE OF AMERICA: Incorporate
grade crossing-related geographic data, such as those currently being
prepared by the Federal Railroad Administration, into your navigation
applications to provide road users with additional safety cues and to reduce
the likelihood of crashes at or near public or private grade crossings.

TO
THE NORTH AMERICAN CARTOGRAPHIC INFORMATION SOCIETY: Use existing newsletters
and other routine forms of communication with your members to highlight the
importance of creating navigation applications that incorporate grade
crossing-related geographic data, such as those currently being prepared by
the Federal Railroad Administration, to provide road users with additional
safety cues and to reduce the likelihood of crashes at or near public or
private grade crossings.

TO
THE CANADIAN NATIONAL RAILWAY: Develop and implement a positive train control
system that includes collision avoidance capabilities on main line tracks,
establishing priority requirements for high-risk corridors, such as those
where passenger trains operate.

TO
THE FEDERAL TRANSIT ADMINISTRATION: Advise all rail transit operators that
have train control systems capable of monitoring train movements to determine
whether their systems have adequate safety redundancy if losses in train
detection occur. If a system is susceptible to single point failures, urge
and verify that corrective action is taken to add redundancy by evaluating
track occupancy data on a real-time basis to automatically generate alerts
and speed restrictions to prevent train collisions. (Urgent)

TO
ALSTOM SIGNALING, INC.: Develop and implement periodic inspection and
maintenance guidelines for use by the Washington Metropolitan Area Transit
Authority and other rail transit operators and railroads equipped with
General Railway Signal Company audio frequency track circuit modules and
assist them in identifying and removing from service all modules that exhibit
pulse-type parasitic oscillation in order to ensure the vitality and
integrity of the automatic train control system.

TO
THE FEDERAL RAILROAD ADMINISTRATION: Require railroads to install, along main
lines in nonsignaled territory not equipped with positive train control,
appropriate technology that warns approaching trains of incorrectly lined
main track switches sufficiently in advance to permit stopping.

TO
CANADIAN PACIFIC RAILWAY LIMITED, KANSAS CITY SOUTHERN RAILWAY COMPANY,
NORFOLK SOUTHERN RAILROAD, AND UNION PACIFIC RAILROAD: Discontinue the use of
after-arrival track authorities for train movements in nonsignaled territory
not equipped with a positive train control system.

TO
ALL RAILROADS SUBJECT TO THE POSITIVE TRAIN CONTROL PROVISIONS OF THE RAIL
SAFETY IMPROVEMENT ACT OF 2008: Provide positive train control implementation
update reports to the Federal Railroad Administration every 6 months until
positive train control implementation is complete. The update reports should
consist of two sections: components and training. The components section
should include a description of the positive train control component to be
implemented, the number of components, the number of components completed on
the report date, the number of components that remain to be completed, the
overall completion percentage, and the estimated completion date. Components
are defined as locomotives, wayside units, switches, base station radios, wayside
radios, locomotive radios, and any new and novel technologies that are part of a positive
train control system. The training section shall include the number of
safety-related employees and equivalent railroad carrier contractors and subcontractors that need to be trained, by
class and craft; minimum training standards for those employees and
contractors, meaning the knowledge of and ability to comply with federal
railroad safety laws and regulations and carrier rules and procedures to
implement positive train control; the
percentage of employees who have completed training;
the percentage of employees who remain to be trained; and the
estimated date that training will be completed.